White Rock Medical Center

All Charges

Charge

Type

Setting

Price

777353802

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	990958
Hospital Revenue Code	278
Min. Negotiated Rate	$117.63
Max. Negotiated Rate	$941.04
Rate for Payer: Amerigroup CHIP/Medicaid	$117.63
Rate for Payer: BCBS of TX Blue Advantage	$392.10
Rate for Payer: BCBS of TX Blue Essentials	$470.52
Rate for Payer: BCBS of TX PPO	$522.80
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Medicaid	$941.04
Rate for Payer: Molina CHIP/Medicaid	$941.04
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Parkland Medicaid	$941.04
Rate for Payer: Scott and White EPO/PPO	$653.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.04
Rate for Payer: Superior Health Plan EPO	$177.75

777353802

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	990958
Hospital Revenue Code	278
Min. Negotiated Rate	$326.75
Max. Negotiated Rate	$653.50
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Commercial	$326.75
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Scott and White EPO/PPO	$653.50

777353822

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991035
Hospital Revenue Code	278
Min. Negotiated Rate	$117.63
Max. Negotiated Rate	$941.04
Rate for Payer: Amerigroup CHIP/Medicaid	$117.63
Rate for Payer: BCBS of TX Blue Advantage	$392.10
Rate for Payer: BCBS of TX Blue Essentials	$470.52
Rate for Payer: BCBS of TX PPO	$522.80
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Medicaid	$941.04
Rate for Payer: Molina CHIP/Medicaid	$941.04
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Parkland Medicaid	$941.04
Rate for Payer: Scott and White EPO/PPO	$653.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.04
Rate for Payer: Superior Health Plan EPO	$177.75

777353822

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991035
Hospital Revenue Code	278
Min. Negotiated Rate	$326.75
Max. Negotiated Rate	$653.50
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Commercial	$326.75
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Scott and White EPO/PPO	$653.50

777354202

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	990959
Hospital Revenue Code	278
Min. Negotiated Rate	$117.63
Max. Negotiated Rate	$941.04
Rate for Payer: Amerigroup CHIP/Medicaid	$117.63
Rate for Payer: BCBS of TX Blue Advantage	$392.10
Rate for Payer: BCBS of TX Blue Essentials	$470.52
Rate for Payer: BCBS of TX PPO	$522.80
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Medicaid	$941.04
Rate for Payer: Molina CHIP/Medicaid	$941.04
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Parkland Medicaid	$941.04
Rate for Payer: Scott and White EPO/PPO	$653.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.04
Rate for Payer: Superior Health Plan EPO	$177.75

777354202

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	990959
Hospital Revenue Code	278
Min. Negotiated Rate	$326.75
Max. Negotiated Rate	$653.50
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Commercial	$326.75
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Scott and White EPO/PPO	$653.50

777354822

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991034
Hospital Revenue Code	278
Min. Negotiated Rate	$117.63
Max. Negotiated Rate	$941.04
Rate for Payer: Amerigroup CHIP/Medicaid	$117.63
Rate for Payer: BCBS of TX Blue Advantage	$392.10
Rate for Payer: BCBS of TX Blue Essentials	$470.52
Rate for Payer: BCBS of TX PPO	$522.80
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Medicaid	$941.04
Rate for Payer: Molina CHIP/Medicaid	$941.04
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Parkland Medicaid	$941.04
Rate for Payer: Scott and White EPO/PPO	$653.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.04
Rate for Payer: Superior Health Plan EPO	$177.75

777354822

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991034
Hospital Revenue Code	278
Min. Negotiated Rate	$326.75
Max. Negotiated Rate	$653.50
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Commercial	$326.75
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Scott and White EPO/PPO	$653.50

777355022

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991021
Hospital Revenue Code	278
Min. Negotiated Rate	$117.63
Max. Negotiated Rate	$941.04
Rate for Payer: Amerigroup CHIP/Medicaid	$117.63
Rate for Payer: BCBS of TX Blue Advantage	$392.10
Rate for Payer: BCBS of TX Blue Essentials	$470.52
Rate for Payer: BCBS of TX PPO	$522.80
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Medicaid	$941.04
Rate for Payer: Molina CHIP/Medicaid	$941.04
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Parkland Medicaid	$941.04
Rate for Payer: Scott and White EPO/PPO	$653.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$941.04
Rate for Payer: Superior Health Plan EPO	$177.75

777355022

Facility

$1,307.00

Service Code	HCPCS C1713
Hospital Charge Code	991021
Hospital Revenue Code	278
Min. Negotiated Rate	$326.75
Max. Negotiated Rate	$653.50
Rate for Payer: Cash Price	$888.76
Rate for Payer: Cigna Commercial	$326.75
Rate for Payer: Multiplan Auto	$653.50
Rate for Payer: Multiplan Commercial	$653.50
Rate for Payer: Multiplan Workers Comp	$653.50
Rate for Payer: Scott and White EPO/PPO	$653.50

777355532

Facility

$1,155.30

Service Code	HCPCS C1713
Hospital Charge Code	994018
Hospital Revenue Code	278
Min. Negotiated Rate	$103.98
Max. Negotiated Rate	$831.82
Rate for Payer: Amerigroup CHIP/Medicaid	$103.98
Rate for Payer: BCBS of TX Blue Advantage	$346.59
Rate for Payer: BCBS of TX Blue Essentials	$415.91
Rate for Payer: BCBS of TX PPO	$462.12
Rate for Payer: Cash Price	$785.60
Rate for Payer: Cigna Medicaid	$831.82
Rate for Payer: Molina CHIP/Medicaid	$831.82
Rate for Payer: Multiplan Auto	$577.65
Rate for Payer: Multiplan Commercial	$577.65
Rate for Payer: Multiplan Workers Comp	$577.65
Rate for Payer: Parkland Medicaid	$831.82
Rate for Payer: Scott and White EPO/PPO	$577.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$831.82
Rate for Payer: Superior Health Plan EPO	$157.12

777355532

Facility

$1,155.30

Service Code	HCPCS C1713
Hospital Charge Code	994018
Hospital Revenue Code	278
Min. Negotiated Rate	$288.82
Max. Negotiated Rate	$577.65
Rate for Payer: Cash Price	$785.60
Rate for Payer: Cigna Commercial	$288.82
Rate for Payer: Multiplan Auto	$577.65
Rate for Payer: Multiplan Commercial	$577.65
Rate for Payer: Multiplan Workers Comp	$577.65
Rate for Payer: Scott and White EPO/PPO	$577.65

777655562

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	991134
Hospital Revenue Code	278
Min. Negotiated Rate	$646.09
Max. Negotiated Rate	$1,292.17
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Commercial	$646.09
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Scott and White EPO/PPO	$1,292.17

777655562

Facility

$2,584.34

Service Code	HCPCS C1713
Hospital Charge Code	991134
Hospital Revenue Code	278
Min. Negotiated Rate	$232.59
Max. Negotiated Rate	$1,860.72
Rate for Payer: Amerigroup CHIP/Medicaid	$232.59
Rate for Payer: BCBS of TX Blue Advantage	$775.30
Rate for Payer: BCBS of TX Blue Essentials	$930.36
Rate for Payer: BCBS of TX PPO	$1,033.74
Rate for Payer: Cash Price	$1,757.35
Rate for Payer: Cigna Medicaid	$1,860.72
Rate for Payer: Molina CHIP/Medicaid	$1,860.72
Rate for Payer: Multiplan Auto	$1,292.17
Rate for Payer: Multiplan Commercial	$1,292.17
Rate for Payer: Multiplan Workers Comp	$1,292.17
Rate for Payer: Parkland Medicaid	$1,860.72
Rate for Payer: Scott and White EPO/PPO	$1,292.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,860.72
Rate for Payer: Superior Health Plan EPO	$351.47

777656562

Facility

$2,584.33

Service Code	HCPCS C1713
Hospital Charge Code	991197
Hospital Revenue Code	278
Min. Negotiated Rate	$232.59
Max. Negotiated Rate	$1,860.72
Rate for Payer: Amerigroup CHIP/Medicaid	$232.59
Rate for Payer: BCBS of TX Blue Advantage	$775.30
Rate for Payer: BCBS of TX Blue Essentials	$930.36
Rate for Payer: BCBS of TX PPO	$1,033.73
Rate for Payer: Cash Price	$1,757.34
Rate for Payer: Cigna Medicaid	$1,860.72
Rate for Payer: Molina CHIP/Medicaid	$1,860.72
Rate for Payer: Multiplan Auto	$1,292.16
Rate for Payer: Multiplan Commercial	$1,292.16
Rate for Payer: Multiplan Workers Comp	$1,292.16
Rate for Payer: Parkland Medicaid	$1,860.72
Rate for Payer: Scott and White EPO/PPO	$1,292.16
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,860.72
Rate for Payer: Superior Health Plan EPO	$351.47

777656562

Facility

$2,584.33

Service Code	HCPCS C1713
Hospital Charge Code	991197
Hospital Revenue Code	278
Min. Negotiated Rate	$646.08
Max. Negotiated Rate	$1,292.16
Rate for Payer: Cash Price	$1,757.34
Rate for Payer: Cigna Commercial	$646.08
Rate for Payer: Multiplan Auto	$1,292.16
Rate for Payer: Multiplan Commercial	$1,292.16
Rate for Payer: Multiplan Workers Comp	$1,292.16
Rate for Payer: Scott and White EPO/PPO	$1,292.16

7mm x 40mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992560
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

7mm x 40mm .035 Saber PTA balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992560
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

7mm x 4cm x 80cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992561
Hospital Revenue Code	272
Rate for Payer: Cash Price	$385.90

7mm x 4cm x 80cm Saber Balloon

Facility

$567.50

Service Code	HCPCS C1726
Hospital Charge Code	992561
Hospital Revenue Code	272
Min. Negotiated Rate	$51.08
Max. Negotiated Rate	$408.60
Rate for Payer: Amerigroup CHIP/Medicaid	$51.08
Rate for Payer: BCBS of TX Blue Advantage	$170.25
Rate for Payer: BCBS of TX Blue Essentials	$204.30
Rate for Payer: BCBS of TX PPO	$227.00
Rate for Payer: Cash Price	$385.90
Rate for Payer: Cigna Medicaid	$408.60
Rate for Payer: Molina CHIP/Medicaid	$408.60
Rate for Payer: Multiplan Auto	$368.88
Rate for Payer: Multiplan Commercial	$368.88
Rate for Payer: Multiplan Workers Comp	$368.88
Rate for Payer: Parkland Medicaid	$408.60
Rate for Payer: Scott and White EPO/PPO	$283.75
Rate for Payer: Superior Health Plan CHIP/Medicaid	$408.60
Rate for Payer: Superior Health Plan EPO	$77.18

80-0318

Facility

$1,485.88

Hospital Charge Code	994023
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,010.40

80-0318

Facility

$1,485.88

Hospital Charge Code	994023
Hospital Revenue Code	272
Min. Negotiated Rate	$133.73
Max. Negotiated Rate	$1,069.83
Rate for Payer: Amerigroup CHIP/Medicaid	$133.73
Rate for Payer: BCBS of TX Blue Advantage	$445.76
Rate for Payer: BCBS of TX Blue Essentials	$534.92
Rate for Payer: BCBS of TX PPO	$594.35
Rate for Payer: Cash Price	$1,010.40
Rate for Payer: Cigna Medicaid	$1,069.83
Rate for Payer: Molina CHIP/Medicaid	$1,069.83
Rate for Payer: Multiplan Auto	$965.82
Rate for Payer: Multiplan Commercial	$965.82
Rate for Payer: Multiplan Workers Comp	$965.82
Rate for Payer: Parkland Medicaid	$1,069.83
Rate for Payer: Scott and White EPO/PPO	$742.94
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,069.83
Rate for Payer: Superior Health Plan EPO	$202.08

80-0387

Facility

$1,611.72

Hospital Charge Code	994024
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,095.97

80-0387

Facility

$1,611.72

Hospital Charge Code	994024
Hospital Revenue Code	272
Min. Negotiated Rate	$145.05
Max. Negotiated Rate	$1,160.44
Rate for Payer: Amerigroup CHIP/Medicaid	$145.05
Rate for Payer: BCBS of TX Blue Advantage	$483.52
Rate for Payer: BCBS of TX Blue Essentials	$580.22
Rate for Payer: BCBS of TX PPO	$644.69
Rate for Payer: Cash Price	$1,095.97
Rate for Payer: Cigna Medicaid	$1,160.44
Rate for Payer: Molina CHIP/Medicaid	$1,160.44
Rate for Payer: Multiplan Auto	$1,047.62
Rate for Payer: Multiplan Commercial	$1,047.62
Rate for Payer: Multiplan Workers Comp	$1,047.62
Rate for Payer: Parkland Medicaid	$1,160.44
Rate for Payer: Scott and White EPO/PPO	$805.86
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,160.44
Rate for Payer: Superior Health Plan EPO	$219.19

80-0759

Facility

$1,355.20

Hospital Charge Code	994025
Hospital Revenue Code	272
Min. Negotiated Rate	$121.97
Max. Negotiated Rate	$975.74
Rate for Payer: Amerigroup CHIP/Medicaid	$121.97
Rate for Payer: BCBS of TX Blue Advantage	$406.56
Rate for Payer: BCBS of TX Blue Essentials	$487.87
Rate for Payer: BCBS of TX PPO	$542.08
Rate for Payer: Cash Price	$921.54
Rate for Payer: Cigna Medicaid	$975.74
Rate for Payer: Molina CHIP/Medicaid	$975.74
Rate for Payer: Multiplan Auto	$880.88
Rate for Payer: Multiplan Commercial	$880.88
Rate for Payer: Multiplan Workers Comp	$880.88
Rate for Payer: Parkland Medicaid	$975.74
Rate for Payer: Scott and White EPO/PPO	$677.60
Rate for Payer: Superior Health Plan CHIP/Medicaid	$975.74
Rate for Payer: Superior Health Plan EPO	$184.31

Know your out-of-pocket cost for care.

All Charges